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Health and Disability Commissioner At 0150 on 11 February 2001, Mrs A was re-admitted to Delivery Suite as her contractions were increasingly intense. Ms D was called back to the hospital. Mrs A’s blood pressure and observations were recorded as normal. The CTG recorded a baseline fetal heart rate of 140 bpm at 0230. Pinkish liquor was detected. Contractions were still 2:10, lasting 45–50 seconds. At 0415, Mrs A requested a progress update. Ms D noted that the cervix was soft and effacing. The fetal heart rate was recorded as 130bpm and liquor was clear. After discussing pain management, Mrs A decided to opt for an epidural. At 0500, an epidural was inserted and Syntocinon augmentation of 2ml/hr began at 0540. This was increased to 4ml/hr at 0615. At 0630 contractions were occurring at the rate of 3:10 and lasting 60 seconds. The contractions were moderately strong but Mrs A was noted to be comfortable. The fetal heat rate was recorded as 130–140 bpm. The epidural was topped up at 0655. Some shallow decelerations were noted. At 0800 contractions were occurring at the rate of 4:10. Syntocinon was reduced to 2ml/hr. Dr B was advised of Mrs A’s re-admission and progress. At 0830, another doctor reviewed Mrs A on behalf of Dr B. Persistent shallow type 1 decelerations were noted and the fetal heart baseline was recorded as 140–150–120. An epidural top-up was given. Syntocinon was increased to 4ml/hr at 1030. A contraction rate of 3:10 is recorded at 1000 and 5:10 at 1130. Active labour — 11 February 2001 Dr B saw Mrs A at 1115 in the Delivery Suite. Mrs A was recorded as being in active labour (3.5 cm dilated). Dr B wrote in the notes: “should aim to deliver within 6–8 hours”. Dr B decided the contractions were reasonable but needed to be augmented by an increase in Syntocinon. Ms D confirmed to ACC that the labour was slow to establish and Mrs A consented to Dr B’s plan for augmentation and epidural administration. An epidural top-up was provided at 1045 and Syntocinon was increased to 8ml/hr at 1100. A contraction rate of 5:10 with shallow decelerations was recorded at 1130. At 1145, Syntocinon was decreased to 6mls/hr and persisting type 1 decelerations were noted. An epidural top-up was provided at 1230 and the baseline fetal heart rate was recorded as 145 at 1245. At 1300 Mrs A reported an increasing pressure in the rectum, which is usually a sign that the labour is progressing to second stage (pushing). The notes record 7cm dilation at 1315 and the fetal heart rate at that time was 136–140 bpm, with continuing shallow dips. A further epidural top-up was provided at 1400. Ms D 4 19 September 2006 Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name
Opinion/05HDC16711 advised ACC that she discussed the continuing type one decelerations and the rate of Syntocinon with Dr B at various times, and that Dr B advised her to slowly increase the Syntocinon. However, the labour was still slow to progress. Mrs A advised me that she was not given any alternatives to progressing with the induced labour, and that the option of Caesarean section was not discussed. In response to my provisional opinion, Dr B stated that she did mention the option of a Caesarean section throughout the first stage of labour. However, there is no record of such discussions noted in the clinical record. At 1440 Dr B reviewed Mrs A and noted her (Dr B’s) plan to increase Syntocinon to 8mls/hr. Mrs A advised me that she was not involved in this decision, as Dr B called Ms D out of the birthing room to discuss this plan. Mrs A recalls that Ms D and Dr B returned to the birthing room but that Ms D looked concerned, opened Mrs A’s Matpro book to the birth plan page and left it on the side of the bed. Mrs A said she asked, “Are you alright [Ms D], what is wrong?” Mrs A advised me that she got no response from either Ms D or Dr B. Mrs A said that Ms D opened her antenatal book to what Mrs A believes was her birth plan. In response to this investigation, Ms D advised me that communication with Mr and Mrs A was open, honest and friendly. Ms D could not recall handing the Matpro book to Mrs A, but stated that if she did so, there was no intention to communicate any message or to dissent from Dr B’s management of care. Syntocinon was increased to 8mls/hr at 1440, 12mls/hr at 1455, 16mls/hr at 1510 and 20mls/hr at 1540. A contraction rate of 5:10 is recorded at 1455 and 1540, with a baseline fetal heart rate of 145–150bpm. No abnormalities were recorded. Mrs A was again reviewed by Dr B at 1600. Mrs A was fully dilated and the plan was to start pushing in 30–45 minutes. Contractions had increased to 6:10 by 1630. The partogram records an increase in fetal heart rate to 160 bpm by 1630. The CTG tracing ends at 1720. Dr B advised me that, at this stage, Mrs A had been in labour for six hours, which was consistent with the birth plan discussed earlier at 1115. At 1730, Dr B noted that Mrs A had been actively pushing for one hour with some late decelerations but good recovery so far. Dr B described the CTG in the clinical notes as “ok”. In her response to this investigation, Dr B described the CTG tracings as showing “good recovery from decelerations and did not show a pattern of fetal asphyxiation”. However, I note that in Mrs A’s discharge summary dated 13 February 2001, the CTG is described as “abnormal”. It was agreed that Dr B would use a ventouse-assisted delivery, and Mrs A was transferred to a delivery theatre. A CTG machine was not available initially in the delivery theatre as all of the mobile units were in use. The CTG machine that had been used in the labour room was fixed to the wall and could not be transferred with Mrs A. Ms D negotiated with a hospital midwife, and a CTG machine was eventually 19 September 2006 5 Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
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